Transcript Welcome to the Emergency Department

Welcome to the Emergency Department
Loma Linda University Medical Center
What should you get out of this
Rotation?
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See something cool that you won’t deal with everyday in your chosen
specialty.
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Learn about how Emergency Medicine interacts with the other
specialty services.
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Appreciate some of the unique challenges and opportunities inherent
to the acute care setting.
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Practice forming and risk-stratifying differential diagnoses.
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Appropriately apply diagnostic strategies to the acute workup of
patients.
Why an Emergency Medicine
rotation is for everybody
Almost regardless of which specialty you are entering, you will interact
extensively with the emergency department throughout your career.
This experience offers a valuable chance to learn what goes into our
medical care, and understand how we can all work together to help our
patients in the best way possible.
Plus, it’s really fun...
Our Expectations
Teamwork
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Although we see our patients in parallel, rather than in the traditional
inpatient team model, you are still part of the team.
Get involved in resuscitations and traumas that “belong” to the
senior residents.
If you hear about a procedure that you’re interested in, ask to be
involved.
Your patient flow and your attitude affect everyone else.
Our Expectations
Own your patients
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The patient is your responsibility from the time you pick up the chart
until they physically leave the ED.
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Reexamine the patient as often as needed.
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Be proactive in following up on test results.
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If something is delayed, find out why and try to fix it.
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Get discharge materials ready as soon as everything else is
finished.
Our Expectations
Productivity
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You expected to see a minimum of 10-15 patients/shift depending on your
level of training (i.e., PGY-1 vs PGY-3).
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At times, the RIC (Resident-in-Charge) may assign you charts out of the rack
to help with department flow.
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Expect to carry up to 4-5 undifferentiated or undispositioned patients at a time.
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Plan on one brief meal break per shift, and coordinate the timing with the RIC
or attending physician. Due to the fluctuating number of critically ill patients
that present to the ED, the timing of breaks are coordinated to optimize patient
care needs.
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Check in with the RIC any time you need to step out of the department.
Our Expectations
Professionalism
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Be on time and work hard until your shift is over. Then relax.
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If you need to call in sick or have other issues with a scheduled
shift, please contact the chief as early as possible. Our contact
information is on the last slide.
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If you have questions about the sick policy, please ask.
Our Expectations
Patient Care
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Nurses may ask you too "clear this patient off a backboard"; Do not
clear spines unless directly supervised by an attending.
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If you have a patient who is crashing or unstable, grab a senior or
attending right away.
Orientation to the Department
When you arrive for your first shift, find the senior resident on duty and ask
them for a tour. They should show you:
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Different treatment areas/designations
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Supply locations, including carts and storage rooms
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Ultrasound machine
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The rack (new patients)
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The charge nurse and unit secretary
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Where to find paperwork
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FirstNet, including the tracking board, notes, and discharge instructions
Important People
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Resident in Charge
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Charge Nurse (55070)
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Techs / Unit Secretary
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ED Pharmacist
When you pick up a new patient
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Take the chart highest on the rack (do not
go out of order or cherry pick!)
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The location is written on the colored dot
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Colored dots = acuity
✤ Red: Dying/Critical
✤ Orange: Emergent or high pain level
✤ Yellow: Urgent
✤ Green: Low acuity
✤ Blue: Stable
1: Assign Yourself to the Patient
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Be sure to sign up for the patient as soon as you pick up the chart.
The associated times are logged and evaluated. If you forget and
need to adjust it later, we can show you how.
2: Sign the
Chart
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Put a provisional diagnosis at
the top (ex. abdominal pain)
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Sign and print your name
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Date and time the orders
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Place a patient sticker at the
bottom
3: See the Patient
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You may want to spend up to 5 minutes looking up the patient in the
system.
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Doing the H&P interview should take no more than 15-20 minutes.
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Be intelligently detail-oriented. Form your list of differentials as you
go, and ask the questions that pertain.
4: Present to
the Attending
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Give them a patient sticker
Tell the room number and the patient’s
basic information
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Be concise and organized in your
presentation
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Formulate a differential and plan together
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Try to be proactive with your decision
making. Don’t just ask what they want
you to do.
Order labs and imaging as agreed upon
with the attending
5: Communicate
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Give orders to the tech in the patient’s area to be placed in the
computer.
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Contact Radiology if necessary (usually nights and weekends)
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Discuss the plan with the patient and with their nurse.
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Keep the patient's nurse and the charge nurse informed about pending
admissions and discharges.
6: Disposition
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Once you have all your data
back, and you have reassessed
the patient, recheck with the
attending regarding a consult or
discharge.
For Admissions: Click the ‘ED
MD Admit’ box to log the time
as soon as you decide the
patient warrants admission.
Note that this isn’t necessarily
the same as the time you
actually call a consult.
6: Disposition
For consults:
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Ask the unit secretary to send the page. When they do, they should
also start the appropriate timer. It’s still your responsibility to
double-check that it happens.
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For MOD admissions, have the attending send a page, and mark
the consult timer yourself.
6: Disposition
For consults:
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Be concise and specific.
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Every call should involve a clear question or reason why the patient
requires their care.
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Provide them with the pertinent details to frame your question.
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Decide with the attending before calling as to who the appropriate
consulting service will be.
6: Disposition
For discharges:
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You write discharge instructions by accessing ‘Patient Education’ in the
tracking board.
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Select the most appropriate one(s) using the search boxes. Make sure
you include an "ED Transition of Care Record."
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On the first line, type in whatever instructions you specifically want them
to follow. This includes when to follow up, phone numbers to call,
pending results, and precautions.
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Print the instructions, a work or school note if needed, write and attach
any prescriptions, and have the attending sign them.
6: Disposition
6: Disposition
For discharges:
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When discharging a patient, avoid open ended instructions (return if
you’re not feeling better). Instead, always give a specific date,
place, and reason to follow up (Call your primary doctor in 2 days if
you’re still vomiting). Leave it to them to decide if they actually want
to follow the instructions.
Supervision
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You may write orders for pain meds as appropriate before chiefing
with an attending.
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Present to the attending before ordering all other labs, imaging, etc.
Some standard order sets may be started by the nurses before you
get the chart.
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Avoid seeing a new patient until the previous one is staffed and in
progress (at least for the beginning of the month)
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A senior resident or the attending is always available to supervise any
procedure which you aren’t comfortable doing on your own.
Charting
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If there is no scribe, you are responsible for the full note. Choose “ED
H&P” as the note type, and remember to send it to the attending for a
signature.
If there is a scribe present, choose “ED Resident” as your note type.
These do not need to be sent to the attending for a signature unless
they specifically ask you to.
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The addendum should focus on your medical decision making. It is
your chance to summarize the pertinent details of the patient’s
history, mention the differential diagnoses you considered, and
explain how the course of the workup led you to your final diagnosis
and/or disposition. Tell the story and make your case.
Medical Students
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Although medical students will chief their patients only to EM senior
residents, they are still encouraged to learn from your patients as well.
Please keep them in mind if you have any interesting cases, exam
findings, imaging, etc.
Signout
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Signouts are a high risk time for emergency medicine, and giving good
signout is a skill that takes practice. You may experience a bit of a
learning curve; that’s normal. (And if the senior residents seem picky,
it’s just because they’ve learned from previous mistakes)
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To help minimize those risks, we have a formal signout checklist on
the program website, which we are asking you to use.
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Here are some of the highlights…
Signout
During the last hour of your shift, you should:
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Finish all minor procedures
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As a rule LPs, lac repairs, reductions, disimpactions, I and Ds,
rectal exams, pelvic exams, etc., should not be signed out.
Check for recommendations or admission orders for all patients
awaiting consultation. Call the consultants again if necessary.
Signout
During the last hour of your shift, you should:
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Update all your patients and their nurses about the current plan,
and tell them which doctor will be taking over for you when you
leave.
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Take some time to work on your notes.
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For patients awaiting transfer to an outside facility (Kaiser,
BMC…) you must complete the note before you leave.
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All notes must be completed within 24 hours.
Signout
During the last hour of your shift, you should:
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Formulate a final plan with the attending
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If [blank] is positive, then …
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If [blank] is negative, then …
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If patient will be admitted regardless of pending tests, go ahead and
call the admitting team (even if all the labs/test aren't back)
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Prepare discharge and prescriptions for patients who will likely be
discharged
Signout
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Print out a list of your patients for the oncoming resident.
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At the end of your shift, sign out to the senior resident who started
most recently.
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Your sign out must include every patient still physically in the
department, even if they are admitted, discharged, or have a consult
pending.
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Bedside rounds are at the oncoming resident’s discretion, and
recommended for potentially unstable patients.
Signout
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Use the following template to review each patient:
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D isposition (Admit/discharge/pending and sick/not sick)
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A ssessment (Brief history with a working diagnosis and relevant findings)
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D iagnostics pending (Labs, Imaging)
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S pecial Concerns (any potential issues that may arise with a specific patient)
If you sign out pending diagnostics, be sure to communicate what to do in case of
the various foreseeable potential outcomes.
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i.e., it’s not enough to say “if the CT looks normal, the patient can go.” Which
kinds of abnormal are you worried about? If it’s abnormal, what’s your plan for
the next steps?
How We Think
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Depending on your background and level of experience, you probably
have developed your own way of thinking about each medical
encounter that works for your specialty.
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There are some unique aspects of Emergency Medicine that affect our
cognitive approach, which we expect you to appreciate during this
rotation.
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Here are some of the most essential points:
How We Think
Emergency Medicine Treatment and Active Labor Act (EMTALA)
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Places a responsibility on hospitals to stabilize anyone with a potential
‘emergent medical condition’ regardless of ability to pay before other
transfer or discharge can be considered. This is a big factor behind our
‘worst first’ mindset.
The exception is a transfer for “higher level of care.” This means that
although an emergent medical condition still exists, the sending facility is
not capable of appropriately stabilizing it.
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You could fill entire legal libraries with what has been written about
EMTALA attempting to define its’ intricacies. You only need to come away
from this rotation with a basic understanding of it.
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The bottom line: the ED is the front line for all things EMTALA
How We Think
Tests: the intelligent approach
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What are the pros/cons/sensitivity/specificity of each test I’m
ordering?
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What are the risks of the tests?
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How will the results (either positive or negative) affect my
subsequent management?
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Are there any tools that can potentially help me avoid performing
the test?
How We Think
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Although we commonly talk about “ruling out” and “diagnosing” diseases, it’s
not really that simple. Every decision is really a matter of risk stratifying within
the limits of the information and testing that we have available.
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As an example, do we ever “rule out” a PE? No, we just reach a point when
the likelihood falls below the ability of our tests to further evaluate it.
In Emergency Medicine it’s not always possible to make the final diagnosis
due to the limitations of available studies that can be performed within a short
timeframe. Other patients are waiting to be seen, many with potentially life
threatening pathology.
Our primary goal in EM is to evaluate and treat the immediately life threatening
or disabling diseases and disposition the patient for further care.
How We Think
When we first see a patient, here are the basic questions that we have to
address:
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Is this patient sick or not sick?
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Is this someone who obviously warrants admission, obviously will go
home, or isn’t clear?
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What are the high mortality/morbidity diagnoses that COULD account
for the patient’s presentation? Remember to think “worst first,” rather
than by most likely.
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If the patient doesn’t end up having any of those, what will their follow
up arrangement be? What are the next steps that you should
anticipate?
How We Think
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When you see a patient, use your gestalt assessment to help you form
a broad differential
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Direct your questioning towards those possibilities
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Refine and reprioritize that list as information comes back...
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...until the patient is appropriately risk stratified and dispositioned
accordingly.
Other Rules of Thumb
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Here are a few more random things that will help make your month go
more smoothly:
RME (Rapid Medical Evaluation)
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You’ll notice that some charts already have orders marked and in
progress, even though you just picked the chart up out of the rack
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Sometimes nurses work off of protocols (chest pain, abdominal pain)
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Other times a PA, NP, Senior Resident, or Attending may start a basic
workup from triage to help expedite their care
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You still are responsible for that patient the same as for any other
chart you pick up
ED Observation Unit
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Ideal for patients who need up to 24 hours to make a dispo
decision
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You must have a specific end-point in mind. Examples include:
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A patient the needs some time to declare themselves
(dehydration, allergic reaction)
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A patient waiting on a specific therapy (Clindamycin IV x3
prior to discharge, or low risk chest pain waiting on enzymes)
There are three forms that you need to fill out:
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Order forms (specific to the observation diagnosis)
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Abbreviated History & Physical
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Discharge Form (you only have to fill out the first section)
Give the forms to the unit secretary after the attending has signed
them. Don’t forget to mark the ED/MD Admit box on FirstNet.
Checking Order Status
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A magnifying glass on the tracking board means that everything you
ordered is back.
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To check the status of individual orders, right click on the
corresponding box on tracking screen:
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Dispatched: sample not in lab. Check with the nurse to see what
problem may be
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In-lab: lab has sample and running sample
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Complete: sample done
Checking Order Status
Radiology
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Read all your own X-rays and CTs, even if you don’t trust yourself
without the radiology report. (at least LOOK at them)
For any studies besides X-ray and CT, you need to page the radiology
resident covering that service to finalize the order. Their call list is
posted.
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This doesn’t apply to ultrasounds on weekdays from 8a-5p.
Resources
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LLUMC Chief Resident: Matt Barden, MBarden-9126
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RCRMC Chief (LLUMC Backup): Michelle Iwaki,miwaki/9420
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Scheduling: Sha Brennon [email protected]
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EM Department Office: Kathy Haimson and Ruby Navarro
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558-4344, 558-4085